GOVERNMENT OF INDIA

FINAL INVESTIGATION REPORT OF

IN-FLIGHT ENGINE SHUTDOWN INCIDENT TO
M/s SPICEJET LTD. BOEING B737-8, AIRCRAFT VT-MXA ON
03.05.2022 AT CHENNAI.

O/o DIRECTOR AIR SAFETY, SOUTHERN REGION,

INTERNATIONAL CARGO COMPLEX, MEENAMBAKKAM,
CHENNAI-600016

[i]
 FOREWORD

In accordance with Annex 13 to the International Civil Aviation Organization

Convention and the Aircraft (Investigation of Accidents and Incidents) Rules 2017,
the sole objective of this investigation is to prevent aviation incidents and accidents
in the future. It is not the purpose of the investigation to apportion blame or
liability.

This report has been prepared based upon the evidences collected during the
investigation and opinions obtained from the experts. Consequently, the use of this
report for any purpose other than for the prevention of future incidents /accidents,
could lead to erroneous interpretations.

[ii]
 ABBREVIATIONS
Aircraft Incident Aircraft
AMM Aircraft Maintenance Manual
AOC Air Operator Certificate
ATC Air Traffic Control
ATPL Airline Transport Pilot License
CAS Calibrated Air Speed
CG Center of Gravity
CPL Commercial Pilot Licence
CSN Cycles Since New
CVR Cockpit Voice Recorder
DFDR Digital Flight Data Recorder
ELPL English Language Proficiency Level
FAA Federal Aviation Administration
FCOM Flight Crew Operating Manual
FCTM Flight Crew Training Manual
FDR Flight Data Recorder
FDTL Flight and Duty Time Limitations
FL Flight Level
FO Co-Pilot/ First Officer
FRTOL Flight Radio Telephone Operator’s Licence
IATA International Air Traffic Association
ICAO International Civil Aviation Organization
IFR Instrument Flight Rules
IR Instrument Rating
IST Indian Standard Time
LH Left Hand
MEL Minimum Equipment List
Operator AOP Holder of The Incident Aircraft
PF Pilot Flying

[iii]
PIC Pilot in Command
PM Pilot Monitoring
PPC Pilot Proficiency Check
RA Radio Altitude
RWY Runway
SSCVR Solid State Cockpit Voice Recorder
SSFDR Solid State Flight Data Recorder
TSN Time Since New
UTC Coordinated Universal Time
VFR Visual Flight Rules

[iv]
 INDEX
Contents Page no.
SYNOPSIS 2

1. FACTUAL INFORMATION
1.1 History of Flight 3
1.2 Injuries to Persons 3
1.3 Damage to Aircraft 3
1.4 Other damage 4
1.5 Personnel information 4-5
1.6 Aircraft information 5-17
1.7 Meteorological information 17
1.8 Aids to Navigation 17
1.9 Communications 17
1.10 Aerodrome information 18
1.11 Flight recorders 18-19
1.12 Wreckage and impact information 19
1.13 Medical and pathological Information 19
1.14 Fire 19
1.15 Survival aspects 19
1.16 Tests and research 20-24
1.17 Organizational and management information 24-25
1.18 Additional information 25
1.19 Useful or effective investigation Techniques 25

2. ANALYSIS
2.1 Operational aspect of Aircraft 26
2.2 Weather 26
2.3 Engineering aspect of aircraft 27-28

3. CONCLUSIONS
3.1 Findings 28-29
3.2 Probable cause 29

4. SAFETY RECOMMENDATIONS 29

[v]
FINAL INVESTIGATION REPORT OF IN-FLIGHT ENGINE SHUTDOWN
INCIDENT TO M/s SPICEJET LTD. BOEING B737-8, AIRCRAFT VT-MXA
ON 03.05.2022 AT CHENNAI.

1 Aircraft Type Boeing B737-8 MAX

Nationality India
Registration VT-MXA
2 Name of the Owner M/s Sky High LXXX Leasing Company Ltd.

3 Name of the Operator or M/s SpiceJet Ltd.

Hirer
4 Pilot – in –Command Valid ATPL holder

Extent of injuries Nil

5 First Officer Valid CPL holder

Extent of injuries Nil

6 Date and Time of Incident 03rd May 2022, 1430 UTC
(03rd May 2022, 1930 IST)

7 Place of Incident VOMM (Chennai Airport, Chennai, India)

8 Last point of Departure VOMM (Chennai Airport, Chennai, India)

9 Intended place of landing VEDG (Kazi Nazrul Islam Airport, Durgapur, India)

10 Crew on Board 07 (02+05)

11 No. of Passengers on board 179

12 Type of Operation Schedule, Passenger

13 Phase of Operation During Climb

14 Type of Incident SCF-PP (System/Component Failure – Power plant)

(All timings in the report are in UTC)

Page | 1
 SYNOPSIS

On 03rd May 2022, M/s SpiceJet Boeing B737-8 aircraft registration VT-MXA
while operating a scheduled flight from Chennai to Durgapur was involved in an air
turn back incident due Eng#2 in-flight shutdown during climb at 1430UTC. There
were 186 persons including seven crew members on board the aircraft.

The aircraft took off from Chennai at 1412 UTC. While climbing, passing
FL80, “Oil Filter Bypass Light” (OFB Light) illuminated for Engine#2 at 1417 UTC.
Crew started doing checklist and the light was extinguished after levelled out at FL90,
and at about FL93, the OFB light for Engine#2 came once again and remained. Crew
carried out the checklist and it directed to shut down the engine. Crew carried out the
In-Flight Shut Down (IFSD) of the ENG#2 and declared PAN PAN.

Further, crew requested to ATC for priority landing and made a safe single
engine landing at Chennai (1448 UTC) and taxied to the parking bay. There was no
fire and injury to any of the occupants on board the aircraft.

The incident was reported to DGCA, subsequently the investigation was

ordered by DGCA under Rule 13(1) of the Aircraft (Investigation of Accidents and
Incidents) Rules, 2017, by appointing the Investigator-in-charge vide order no
DGCA-15018(07)/8/2022-DAS dated 11.05.2022.

The investigation reveals that, the incident occurred due to the ENG#2 Radial
Drive Shaft Ball Bearing cage rivet fatigue failure.

Page | 2
1. Factual Information:

1.1 History of the flight:

On 03/05/2022, M/s SpiceJet, Boeing B737-8 MAX aircraft registration VT-MXA

was operating a scheduled flight (SG331) sector Chennai to Durgapur. Flight SG-
331 was the fifth flight of the day by VT-MXA aircraft. There were 179
passengers and 07 crew members on board the aircraft. There was no abnormality
reported on the aircraft during any of the previous flights on said date and previous
day.

The flight was under the command of PIC holder of ATPL license with Co-Pilot
holder of CPL license and both duly qualified on aircraft type B737-8. The first
sector for the crew on the incident day was Chennai to Durgapur and they had
been provided adequate rest before the flight. Pilot in Command (PIC) was Pilot
Flying (PF) and First Officer (FO) was Pilot Monitoring (PM).

The flight SG331 took off from Chennai at around 1412 UTC. The take-off was
uneventful, weather reported at 1400 UTC was visibility 5000m, mist and winds
calm. While climbing, passing FL80, “Oil Filter Bypass Light” (OFB Light)
illuminated for Engine#2 at 1417 UTC. Crew levelled out at FL90, started non-
normal checklist and the light was extinguished before completion of it. At about
FL93, the OFB light for Engine#2 came once again. Crew carried out the QRH
and it directed to shut down the engine. Crew carried out the In-Flight Shut Down
(IFSD) of the ENG#2 and declared PAN PAN.

Further, crew requested to ATC for priority landing and made a safe single engine
landing at Chennai (1448 UTC) and taxied to the parking bay. All persons on
board were safe and there was no fire reported.

1.2 Injuries to persons:

Injuries Crew Passengers Others

Fatal NIL NIL NIL
Serious NIL NIL NIL
Minor/None NIL/07 NIL/179

Total personnel on board: 186

1.3 Damage to Aircraft:

There was no damage to the aircraft. However, ENG#2 was shut down due
internal failure.

Page | 3
1.4 Other Damage: NIL

1.5 Personnel information:

Details Commander First Officer

Age/Gender 43Years/Male 33 years/Male
Licence type ATPL CPL
Date of issue 12-10-10 26-05-14
Licence Valid up to 29-10-26 22-04-24
Licence Category Aeroplane Aeroplane
Endorsement as PIC C-152, C-172, PA-34,
ATR42/72, B737 300- DA-42, C-172
900
Date of Class I/II
01-10-21 16-07-21
Medical
Medical Exam valid
08-10-22 23-07-22
up to
Date of issue of
22-10-2000 26-05-14
FRTO License
FRTO Licence Valid
12-11-22 22-04-24
up to
Instrument rating done
10-02-22 12-11-21
on
Last PPC done on 10-02-22 12-11-21
Total Flying
9322.31 618.54
Experience
Experience on Type 6163 Hours 28 mins 401 Hours 44 mins
Experience as PIC on
6110 Hours 20 mins NA
Type
Last flown on Type 02-05-22 02-05-22
Total Flying
Experience in last 1 317:33 280:32
year
Total Flying
Experience in last 6 172:33 191:51
months
Total Flying
Experience in last 30 34:25 52:56
days
Total flying
experience in last 7 00:00 19:06
days
Total flying
experience in last 24 00:00 03:46
Hrs.
Duty time last 24 Hrs. 0215 Hrs. 0725 Hrs.
Rest before the flight 2159 Hrs. 1700 Hrs.

Page | 4
 English Language L-5 L-4
Proficiency Level
(ELP)
ELP Valid till 17-12-25 16-08-23

Both the operating crew were current in all training and was not involved in any
serious incident/accident in the past. The licenses of both the cockpit crew and all
the ratings were valid. Both the crew had adequate rest prior to roster for the
incident flight. Both the cockpit crew had undergone pre-flight medical
examination prior to flight and same was negative.

1.6 Aircraft information:

The Boeing B737-8 is a subsonic civil transport aircraft. The aircraft has two high
bypass turbofan LEAP-1B (Leading Edge Aviation Propulsion) engines
manufactured by M/s CFM International. It is for short to medium range flights
with a capacity of up to 210 passengers. The aircraft is certified in Normal
(Passenger) category, for day and night operation under VFR & IFR. The airplane
has a design range of 3,550 nautical miles and maximum operating altitude is
41,000 feet (12496.8m).

The aircraft length is 39.52m, wingspan is 35.91m and height of this aircraft is
12.42m. The distance between main wheel center is 5.72m and has an engine
clearance of 0.54 meters.

Page | 5
 Figure 1: B737-8 External dimensions as shown

1.6.1 Brief Technical Description of CFM turbofan LEAP-1B Engine

The LEAP-1B (Leading Edge Aviation Propulsion) is a high bypass ratio, dual
rotor turbofan engine.

Figure 2: Engine General Description

Page | 6
 Figure 3: Engine Accessory Drive

ENGINE - ACCESSORY DRIVE

General

The accessory drive transmits mechanical energy from the N2 shaft to the
accessory gearbox. The inlet gearbox (IGB) turns the radial drive shaft (RDS). The
RDS turns the transfer gearbox (TGB). The TGB turns the transfer shaft (TS). The
TS turns the accessory gearbox (AGB). The transfer of mechanical energy reverses
when the starter operates.

Inlet Gearbox (IGB)

The IGB transmits mechanical energy from the high-pressure compressor front
shaft to the RDS. It also holds the front of the HPC rotor.
The IGB contains these parts:
• Horizontal bevel gear with coupling/locking nut
• Pinion bevel gear
• Number 3 bearing (roller and ball)
• Number 3 bearing rotating seal.

Radial Drive Shaft (RDS)

The RDS transmits mechanical energy from the IGB to the Transfer Gearbox. The
assembly is located at the 6:00 position (aft looking forward). The RDS has an
inner Radial Drive Shaft and housing, a shaft mid- length ball bearing, and an
outer Radial Drive Shaft and housing. The shaft mid-length bearing gives correct
centering of the RDS in its housing.
Page | 7
 Figure 4: Inner RDS Location

Figure 5: Inner RDS

Transfer Gearbox (TGB)

The TGB transmits mechanical energy from the RDS to the Transfer Drive Shaft.
The TGB is on the fan frame module at the 6:00 position and has:
• Transfer gearbox housing
• Input bevel gear
• Horizontal bevel gear and transfer shaft assembly
Page | 8
Transfer Shaft (TS) and Transfer Tube

The TS has a spline at each end and transmits mechanical energy from the TGB to
the Accessory Gear Box (AGB). The transfer shaft is inside the transfer tube.
The TGB transfer tube is made of an aluminium alloy. The TGB transfer tube
ensures oil containment between the TGB housing and the AGB housing. It also
houses the TGB horizontal bevel gear assembly. It provides a bearing support for
two TGB roller bearings and one TGB ball bearing for the TGB horizontal bevel
gear assembly. The transfer tube attaches to the TGB housing with bolts, and
makes the connection with the AGB.

ENGINE OIL - INDICATING - OIL FILTER BYPASS WARNING SYSTEM

General

The oil filter bypass warning system shows a message when the oil filter is near a
bypass condition. The message shows on the engine indication display. The oil
filter bypass indicating system uses a single, dual element differential pressure
sensor. The signal from the sensor is sent to the EECs which in turn sends the
signal to the Display Processing Computers (DPCs) just before the oil filter
bypass valve opens. The oil filter differential sensor connects with the EEC
through a single connector. The sensor is installed on the lubrication unit.

Functional Description

The oil filter differential pressure sensor monitors the oil pressure difference
between the inlet and the outlet of the oil filter. The oil filter differential pressure
sensor is a dual, strain gauge type pressure sensor. Each element in the sensor
sends an output to the related EEC channel. The EECs change this signal to an
ARINC 429 signal and send it to the DPCs.

Oil Filter Bypass Message

Just before the oil filter bypass valve opens, the EEC sends a signal to the DPCs.
This causes the engine indication display to show the amber OIL FILTER
BYPASS message. There is one OIL FILTER BYPASS message for each
engine.
The amber OIL FILTER BYPASS message flashes initially for 10 seconds, and
then shows continuously. The DPCs do not allow the flash mode during takeoffs
and landings.

ENGINE OIL -- DISTRIBUTION - ODMS UNIT

The oil debris monitoring system (ODMS) unit filters and conditions the signal
from the ODMS sensor, and provides a signal to EEC channel B when it detects
ferrous particles in the scavenge oil. The ODMS unit is under the oil tank, in the
04:00 o'clock position, aft looking forward.

Page | 9
 Functional Description

The ODMS unit receives a pulse from the ODMS sensor when it captures a
ferromagnetic particle. The ODMS unit amplifies and filters the particle pulse,
and compares the pulse magnitude to a threshold. If the signal is larger than the
threshold, the signal is conditioned and sent to EEC channel B. The EECs store
the number of chips that are counted in NVM memory. If the number of pulses
reaches a threshold, the EECs send a maintenance message to the Onboard
Maintenance Function (OMF). At another threshold, the EECs send a signal to
the display processing computers (DPCs), which then show a status message and
turn on the maintenance light. There is an OMF special function to erase the chip
count in the EECs.

1.6.2 Aircraft details:

Air Operator Certificate (AOC) Scheduled Operator's Permit No S-16 which
was valid up to 16th May 2023.
Aircraft Registration VT-MXA
Type of Aircraft Boeing 737-8
Manufacture Serial No. 64505
State of Manufacturing USA
Manufacturing year 2018
Certificate of Registration 4977
Certificate of Airworthiness Number 7080, issued on 05.11.2018
number and issue date
Category Normal
Airworthiness Review Certificate DDG/NR/ARC/2021/179, valid till
number and Validity 10.12.2022
Aircraft TSN / CSN 2976:45 Hrs. / 1593
Minimum crew necessary 2/4
Type of fuel ATF Jet-A1
Aero mobile Licence 31.12.2023
Next schedule maintenance due at C-01 check of aircraft expected on Oct 29,
2022.
Weight Schedule Valid up to 28.10.2023
Maxi. Aircraft Take-off Weight 72302 Kg
Maxi. Aircraft Landing Weight 69308 Kg
For incident sector (Chennai-Durgapur)
Aircraft Take-off Weight 68377 Kg
Aircraft Landing Weight 67200 Kg

Page | 10
 Fuel On-board before Flight 21 ton
Engine Details
Engine - LH RH
Engine Manufacturer CFM CFM
Engine Model Leap-1B Leap-1B
Engine S.no 602673 602691
Date of Manufacture 30.09.2018 30.09.2018
Total Engine Hours/Cycles 2976:45 / 1593 2976:45 / 1593
Engine Time since Last Shop Visit First run Engine First run Engine
Last major check carried out First run Engine First run Engine
Last minor check carried out PS-3 check carried PS-3 check carried
out on Apr 23, 2022. out on Apr 23, 2022.
Borescope inspection Borescope inspection
of SN 602691 on Apr of SN 602673 on Apr
27, 2022. 26, 2022.
Failed Part/ Component in flight Engine Serial number 602691 (RH Engine)

The aircraft was last weighed on 29th Oct 2018 at Seattle, USA and the Weight
Schedule was prepared and duly approved by the office of the Director of
Airworthiness, DGCA New Delhi. Prior to the incident flight the weight and
balance of the aircraft was well within the operating limits.

The aircraft VT-MXA was inducted into M/s SpiceJet on 02.11.2018 and operated
until DGCA issued a Public Notice on 13.03.2019 i.e. “Operation of B-737 MAX
aircraft will not take place from/to Indian airports and transit or enter into Indian
airspace effective from 1030 UTC 13 March 2019 till further notice” due
the Boeing 737 MAX aircraft was grounded globally after two fatal crashes on the
aircraft type. At the time of grounding TSN-1547:03Hrs, CSN-793. As per DGCA
order: DGCA - 25011(02)/2/21 dated August 26, 2021 and after completions of
approved Return to service work package for B737-8(MAX) Aircraft vide DGCA
letter: DEL-11011(13)29/2019-DAWNR/1436 dated November 18, 2021, the
Boeing 737 MAX aircraft returned to service on 09.12.2021.

During grounded period aircraft was preserved under service and protection on 30-
day active storage procedure. Post release to service dated 09.12.2021; aircraft
completed 2976:45 Hrs. (TSN) / 1593 (CSN) before the subject incident on
03.05.2022.

The defect record of the aircraft was scrutinized on the date of occurrence of the
incident and observed that LH Ignition system for ENG#1 declared inoperative,
MEL 74-00-01-01B under CAT’C’ invoked on 01.05.2022 and valid up to
11.05.2022.
Page | 11
1.6.3 Post incident details:

On arrival of aircraft to the bay, during initial inspection of failed Engine#2, the
following observations were made by the arrival AME:

1. On board maintenance function interrogated and found Flight Deck Effect-

(FDE) -: ENG #2 OIL FILTER BYPASS IND with Maintenance Message: 79-
42895 CLIMB - OIL FILTER IMPENDING BYPASS ENG#2 ON.
2. Oil quantity Indication and physical level found satisfactory (ENG#1=20,
ENG#2=21).
3. No evidence of oil leaks observed upon visual inspection.
4. Engine Air inlet area is clean.
5. Oil Debris Monitoring System (ODMS) sensor inspection carried out and
found more metal particles on the magnetic tip. (Refer: Figure 2)
6. Scavenge screens plug inspection carried out & observed that
a. Sump A, B, and C - NIL particles observed.
b. Accessory Gear Box (AGB) –Sump - found with less metal particles (Refer:
Figure 1)
c. Transfer Gear Box (TGB) - TGB 1 & TGB 2 sumps– were found with more
metal particles (Refer: Figure 3)

Subsequently the aircraft was grounded for detailed inspection.

Figure 6: AGB Sump

Page | 12
 Figure 7: ODMS Sensor Figure 8: TGB Sump 1 & 2

1.6.4 Airworthiness Directives and Service Bulletins

The Federal Aviation Administration (FAA) learned of five commanded IFSD

events that occurred on certain CFM LEAP-1B model turbofan engines beginning
in August 2018. The affected CFM LEAP-1B model turbofan engines experienced
multiple RDS bearing cage failures resulting in five IFSDs. M/s CFM's
investigations identified debris on the TGB scavenge screen, A-sump screen, and
other screens. Subsequently, CFM determined that these IFSD events were the
result of inadequate oil flow to the RDS bearing, which caused the RDS bearing
cage to fail.

The FAA has issued the AD 2019-12-01 dt. 18th June 2019 (for certain CFM
International S.A. (CFM) LEAP-1B21, -1B23, -1B25, -1B27, -1B28, -1B28B1, -
1B28B2, -1B28B3, -1B28B2C, -1B28BBJ1, and -1B28BBJ2 model turbofan
engines with certain RDS bearings installed) to address the unsafe condition on
these products. The FAA reviewed M/s CFM Service Bulletin (SB) LEAP-1B-72-
00-0222-01A-930A-D, Issue 007, dated May 17, 2019, which describes procedures
for inspections of TGB scavenge screens and borescope inspection (BSI) of the
RDS bearing. For affected engines with ESN 602500 and higher (the failed engine
s.no 602691):
(A) After the RDS accumulates 50 FHs since new but before accumulating 100
FHs since new, or within 50 FHs after the effective date of this AD, whichever
occurs later, perform an initial inspection of the TGB1 and TGB2 scavenge
screens.
Page | 13
 (B) Thereafter, perform repetitive inspections of the TGB1 and TGB2 scavenge
screens at intervals not exceeding 100 FHs since the last inspection.

And along with the above mandatory instructions, the optional Borescope
Inspection (BSI) may be carried out i.e., once the RDS bearing has accumulated
1,000 FHs since new, operator may perform a BSI of the RDS bearing in
accordance with the Accomplishment Instructions of CFM SB LEAP-1B-72-00-
0222-01A-930A-D dated May 17, 2019. If the results of this BSI are “satisfactory”
then operators are not required to perform the repetitive inspections of the AD until
the RDS bearing accumulates 4,250 FHs since new.

Further, M/s CFM issued SB LEAP-1B-72-00-0317-01A-930A-D, Issue 001, dated

January 9, 2020 for repetitive inspection of the Transfer Gearbox (TGB)
Scavenge Screens and repetitive borescope inspection of RDS bearing cage. As per
the SB, the repetitive TGB screen inspection as follows-
(a) The first TGB screen inspection at 75 FH since new, within a window of ±
25 flight hours.
(b) Repeat TGB screen inspection with an interval not exceeding 100 FH until
engine reaches 1,500 FH since new.
(c) For engines above 1,500 FH since new, TGB screen repetitive inspection is
no longer required.

And the repetitive RDS bearing inspections as follows-

(a) RDS bearing inspection at 1,500 FH since new, within a window of ± 100
flight hours.
(b) Another RDS bearing inspection at 6,000 FH since new, within a window
of ±250 flight hours.

Later, the FAA has issued a new airworthiness directive AD 2020-06-01 dt.
12.03.2020 and it superseded the AD 2019-12-01 dt. 18th June 2019. This AD
requires revising the Airworthiness Limitations Section (ALS) of the applicable
CFM LEAP-1B Engine Shop Manual and the operator's approved continuous
airworthiness maintenance program. This AD provide credit for inspections of the
TGB performed in accordance with CFM SB LEAP-1B-72-00-0222-01A-930A-D,
Issue 007, dated May 17, 2019 (“SB 72-0222”) and CFM SB LEAP-1B-72-00-
0317-01A-930A-D, Issue 001, dated January 9, 2020 (“SB 72-0317”). Although
the service bulletins refer to different maintenance manual tasks, both Service
Bulletins, require inspections meeting the same criteria. This AD requires revising
the ALS to include paragraph 6.B. (2) of ESM 05-29, which requires inspections
of the RDS bearing as specified in SB 72-0317. SB 72-0317 provides the
conditions for taking credit for inspections accomplished before the issuance of SB
72-0317, including inspections accomplished using SB 72-0222. Operators who
meet the conditions specified in SB 72-0317 may take credit for previous
inspections as part of their maintenance program.

Page | 14
Once an operator revises the ALS as required by this AD, the operator has fully
complied with this AD. Compliance with the inspections remains mandatory as
part of the ALS.

M/s CFM issued SB LEAP-1B-72-00-0365-01A-930A-D Issue 002, dated

February 22, 2022 (“SB 72-0365”) as they have identified a sub-population of
engines susceptible to RDS Bearing Cage rivet fatigue failure and Commanded In-
Flight Shutdown (IFSD) due to RDS Bearing failures occurred beyond Service
Bulletin LEAP-1B-72-00-0317-01A-930A-D inspection requirements. This
Service Bulletin recommends extended repetitive Transfer Gearbox (TGB)
Scavenge Screens inspections for engines equipped with Inner RDS Serial
Numbers listed and it is observed that the incident involved Engine#2 s.no 602691
equipped with Inner RDS s.no EE856110 is listed in the SB. Further, CFM
recommends to not install two (2) engines listed in the SB on the same aircraft and
it is to be noted that, the ENG#1 s.no 602673 is not listed in the SB, which means
its not an affected Engine.

The statistical analysis by CFM identified a RDS bearing subpopulation i.e., the
RDS ball bearing cage belongs to batch M13685 (Inner RDS S.no EE856110),
which is one of the batches where it includes 13 cage failure events occurred due to
rivet rupture..

All the above & concerned Airworthiness Directives, mandatory Service Bulletins,
mandatory Modifications on the aircraft and its engine had been complied by the
operator. There were no abnormal observations noticed by airline engineering
during the compliance of the ADs & SBs.

As per M/s CFM, the RDS Bearing failures are caused due to

• Insufficient oil film between cage pilot diameter and inner ring.
• Cage wear is due to
- Inadequate bearing geometry that prevents proper oil film establishment.
- Insufficient oil flow reaching cage journal bearing.
• The Rivets fatigue
- Cage halves assembly not at design intent could contribute to rivets
abnormal stress and early failure.

Page | 15
 Figure 9: RDS bearing and cage (Source: M/s CFM)

Failure Modes:

1. Cage inner diameter wear mode –

Wear replicated in bearing rig test and the wear progression monitored on an
endurance engine showed the cage wear progress was linear and then it slows
down.

Figure 10: Cage wear (Source: M/s CFM)

2. Rivets fatigue mode –

Fleet engines investigations identified few cases of cage halves assembly not at
design intent but the riveting process is human factor dependent. Riveting gaps
contribute to rivet abnormal stress, which is a potential early life failure.

Page | 16
 Figure 11: Rivet fatigue (Source: M/s CFM)

The above two failure modes were addressed by M/s CFM through Service
Bulletins SB 72-0222 & 72-0317 – TGB screen inspections during early life.

As of 03.05.2022 (i.e., from Jun’2021) commanded/un-commanded In-flight

engine shutdowns (IFSDs) worldwide due to OIL FILTER BYPASS (OFB) light
were 09 and the total unscheduled removals worldwide due technical are 90.

1.7 Meteorological Information:

The following is the Met report of Chennai Airport on the date of incident 03rd
May 2022 between 1400 Hrs. to 1500 Hrs.:

Time Wind Visibility Weathe Trend Cloud

Direction/Spee r
d
1400 19008KT 5000m BR NO SIG FEW020
1430 20007KT 5000m BR NO SIG FEW020
1500 19006KT 5000m BR NO SIG FEW020

1.8 Aids to navigation:

All Navigational Aids available at Chennai airport were serviceable. The aircraft
was equipped with standard navigational equipment.

1.9 Communications:

Aircraft is equipped with Very High Frequency transmitter and receiver set and
High Frequency transmitter and receiver set. There was always two-way radio
communications available between the ATC and aircraft.

Page | 17
1.10 Aerodrome information:

Chennai International Airport is in City of Chennai. It is operated & Managed by

Airports Authority of India (AAI). The IATA Location Identifier Code is MAA
and ICAO Location Indicator Code is VOMM. The airport has two runways with
orientation 07/25 and 12/30. Runway 07/25 is the primary runway. The Airport
Co-ordinates are: Lat: 12° 59 42, Long: 080° 10 32 and Elevation: 52 feet (16
meters).

1.11 Flight recorders:

The aircraft was fitted with SSCVR and SSFDR. After the incident at Chennai,
both were replaced and downloaded. The data was retrieved and utilized in the
investigation.

1.11.1 Flight Data Recorder (SSCVR):

CVR details:

Make: L3 Technologies Inc.

Model: FA2100CVR
Serial Number: ULB022036
Part number: 2100-1925-22.
The following observations are made from the data (in relative time):

1. At 01:18:25, while aircraft climbing, Engine#2 Oil filter bypass light

illuminated. PIC advised FO to inform ATC due technical they would like
to maintain FL90 and the same was conveyed by FO to ATC.
2. At 01:19:44, crew when started reading Engine Oil Filter Bypass alert
non-normal checklist, the light extinguishes. On PIC advise, FO requested
for vectors to climb.
3. At 01:21:40, once again Oil filter bypass light illuminated and then FO
informed ATC that they would like to maintain FL100 due technical
issue.
4. At 01:24:33, crew started the Engine Oil Filter Bypass light non-normal
checklist.
5. At 01:30:29, PAN PAN PAN PAN PAN PAN SJ331. We are in single
engine operation was made by P2.
6. The ATC vectored the aircraft for priority landing on RWY07.
7. Crew carried out the checklist and call outs as required.

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 1.11.2 Flight Data Recorder (SSDFDR):

FDR details:

Model: FA2100FDR
Make: L3 Technologies Inc.
Serial Number: 001272136
Part number: 2100-4945-22

The observations made from the provided data are:

Time EVENT
(UTC)
14:12:25 The aircraft took-off from Chennai.
14:17:05 At altitude 7875feet, it is observed that the Oil Filter Bypass
ENG#2 light is illuminated and it got extinguished at 14:17:59hrs
at altitude 8989feet. The CAS was observed to be reduced from
310Kts to 304Kts. There was no other parameter found
exceedance.
14:18:01 Just for one second again the Oil Filter Bypass ENG#2 light is
illuminated and extinguished.
14:20:21 Once again, the Oil Filter Bypass ENG#2 light is illuminated at
altitude 9460feet and remained till 14:30:30hrs. There was no
other parameter found exceedance.
14:23:45 Aircraft at altitude 9805feet the Auto Throttle was disengaged &
Thrust Lever of ENG#2 was closed, the Selected Fuel flow#2
found decreasing and ENG#2 was cutoff at 14:30:30hrs at 9792ft.
14:30:39 It is observed that #2 Low Oil Pressure caution alert came & has
remained thereafter.
14:32:08 At altitude 9793feet, there was master caution and continued till
14:40:14hrs.
14:48:46 Aircraft landed with vertical acceleration of 1.072g.

1.12 Wreckage and Impact Information: NIL.

1.13 Medical and pathological Information: NIL.

1.14 Fire:

There was no fire.

1.15 Survival aspects:

The incident was survivable. There was no injury reported to the passengers,
crew, or any other ground personnel.
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1.16 Tests and research:

1.16.1 Investigation of Failed Engine at Manufacturer Facility:

The failed engine was returned to M/s CFM for disassembly and investigation.
During disassembly, the major findings after investigations performed on the
Radial Drive Shaft are:

Figure 12: Inner Radial Drive Shaft (Main Assembly)

Figure 13: Inner RDS

• Strong wear and spalling on outer ring raceway with a strain hardening on
the surface of the raceway and shoulders over the circumference. The strain
hardening covered 1/3 of the total thickness of the ring and shows a second
quenching then an over tempering on hardness profiles. Raceway with wear
(burrs observed on raceway edges) and spalling all over the circumference.

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 Figure 14: RDS Bearing outer ring Characterization (raceway & shoulders)

Figure 15: RDS Bearing Outer ring Characterization (raceway)

• Overheating signs are also visible on the outer diameter, in regard with the
exhaust oil grooves. Rupture of outer ring slots. Blue and brownish strong oil
discoloration on the external diameter and the lateral face corresponding to
lubrication slot’s location.

Figure 16: RDS Bearing Outer ring Characterization (Outer ring lateral face, TGB side)

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 Figure 17: Fracture of anti-rotation pins (Outer ring lateral face, IGB side)

• Global wear over the circumference of the inner ring raceway and presence of
linear axial marks on the raceway on 270°, mostly with a spacing like distance
between balls. Heavy wear of shoulders and washer.

Figure 18: RDS Bearing Inner ring Characterization (raceway & shoulders)

• Some (8 or 9) axial marks on the raceway show smearing (adhesive wear

probably due to sliding) or spalling next to them. Those axial marks show a
strain hardening area on the surface. These deformations take an axial shape on
the raceway and are distributed all over the circumference, probably at the ball
space. Inner ring expanded by global overheating with loss of shrinking.

Figure 19: RDS Bearing Inner ring Characterization (raceway details)

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 • Cage totally fragmented. Heavy wear on each fragment, no fracture surface or
pocket surface is still visible.

Figure 20: RDS Bearing Cage Characterization (cage fragmented)

• Balls are totally worn, 2 of them up to a cylinder shape. Others with scattered
spalling on most of them. Most of the spalling are partially covered due to balls
rotation or sliding on raceways.

Figure 21: RDS Bearing Ball Characterization (cage fragmented)

As per M/s CFM, the new design is addressing both root causes through the SB 72-
0258 (Cat 3) Issue no. 003 dated 04.11.2022, SB 72-0271 Issue no. 02 dated
11.08.2020. CFM advised the operators to comply with these Service Bulletins at next
shop visit of engine or module. The following are the design modifications -

1. The Design modified to address the cage wear –

• New RDS bearing [1], oil diverter [2} & IGB oil nozzle [3] Makes oil film
back at design intent

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 Figure 22: New design to address the cage wear (Source: M/s CFM)

2. And rivet fatigue is addressed by –

• Improved riveting process to reduce susceptibility to human factor
- Traceability and cage clearance control
- Rivets positioning before applying the load in order to guarantee no
circumferential gap
- New tool to set cage preload during riveting
- Removal of silver from rivet holes
• Improved cage design
- Higher cage stiffness has improved halves cages flatness
- Lowered the rivet stress

Figure 23: Improved riveting with preload (Source: M/s CFM)

1.17 Organizational and management information:

M/s SpiceJet Ltd.:

SpiceJet is scheduled airline based in Delhi, India and operates domestic and
international destinations. The airline is holding a valid Air Operator Certificate
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 no. S-16 issued by DGCA valid up to 16.05.2023. The organization commenced
its operations with the fleet of three Boeing 737-800 aircraft and is consistently
expanding its fleet since start of the operations in May 2005. SpiceJet current
fleet is a composition of 47 Boeing B737 (Passenger & Freighter), 32 DHC-8
Q400 and 13 Boeing B737-8 MAX aircraft. Total fleet of 92 as on date. The 13
Boeing B737 MAX aircraft were inducted into SpiceJet from September 2018
to March 2019.

1.18 Additional information:

1.18.1 FCOM PROCEDURE FOR ENGINE OIL FILTER BYPASS:

1.19 Useful or effective investigation techniques: NIL.

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2. ANALYSIS

2.1 Operational aspect of aircraft:

Both the crew members were medically fit, had valid license, provided adequate
rest, and found to be within FDTL limits before they operated flight SG
331(Chennai-Durgapur) on 03.05.2022. Flight SG-331 was the fifth flight of the
day by VT-MXA aircraft and for both the flight crew it was first flight of the day.
The Pilot in Command performed the duties of the Pilot Flying (PF) and First
Officer performed the duties of Pilot Monitoring (PM).

The aircraft took-off at time 14:12:25UTC & it was uneventful. As per DFDR,
during climb at altitude 7875feet (14:17:05UTC), the Oil Filter Bypass (OFB)
ENG#2 light illuminated. By noticing the OFB light, PF advised PM to inform
ATC due technical we would like to maintain FL90 and the same was conveyed by
PM to ATC. Crew started Engine Oil Filter Bypass Light non-normal checklist as
per FCOM and before completion of the checklist the OFB light got extinguished
at 14:17:59UTC (8989feet). At 14:18:01UTC, just for one second again the Oil
Filter Bypass ENG#2 light was illuminated and extinguished. FO requested for
vectors to climb to ATC.

Further once again, the Oil Filter Bypass ENG#2 light was illuminated at
14:20:21UTC at 9460feet and remained till 14:30:30UTC. Then PF advised PM to
inform ATC that they would like to maintain FL100 due technical issue and same
was conveyed by PM. Crew carried out the checklist as per FCOM procedure of
aircraft at 14:23:45UTC at 9805feet, disengaged the Auto throttle & closed the
Thrust Lever of ENG#2, the Selected Fuel flow#2 found decreasing. Further as per
the non-normal checklist, crew carried out inflight shut down of ENG#2 at
14:30:30UTC at 9792ft. As advised by PF, PM declared PAN PAN and said they
are in single engine operation to the ATC. The ATC vectored the aircraft for
priority landing on RWY07. Later, the crew carried out the checklist and all call
outs as required and carried out safe single engine landing at Chennai at
14:48:46UTC, with vertical acceleration of 1.072g, which is not a hard landing.

From the above it is inferred that the crew actions were in line with the standard
operating procedures as per FCOM.

2.2 Weather:

Prior to take off from Chennai, the weather was fine. The aircraft took off from
Chennai at around 1412 UTC and weather reported for Chennai was within the
crew operating minima. The weather reported was fine with visibility reported
5000 meters with mist and winds calm.

From the above, it is inferred that the weather is not a factor to the incident.

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2.3 Engineering aspect of the aircraft:

M/s SpiceJet Boeing B737-8 MAX aircraft MSN 64505, Indian Registration VT-
MXA with CFM LEAP 1B Engines, was registered with DGCA under the
ownership of M/s Sky High LXXX Leasing Company Ltd. on 02nd November
2018. The aircraft is registered under Category 'A' and the Certificate of
Registration No is 4977. As on 3rd May 2022, the aircraft had logged 2976:45
Airframe Hours and 1593 Cycles. The Aircraft was operated under Scheduled
Operator's Permit No S-16 which was valid as on date.

Boeing B737-8 MAX aircraft and its engines are being maintained as per the
maintenance program approved by the Regional Airworthiness Office, O/o
DGCA, New Delhi. The aircraft weight and Center of Gravity (CG) were within
limits.

Transit inspections are carried out as per approved Transit Inspection schedules
and all the higher inspection schedules include checks/ inspection as per the
manufacturer's guidelines as specified in the Maintenance Program and are
approved by the Continuing Airworthiness Manager (CAMO) — post holder for
Continuous Airworthiness.

The statistical analysis by CFM identified a RDS bearing subpopulation i.e., the
RDS ball bearing cage belongs to batch M13685, which is one of the batches
where it includes 13 cage failure events occurred due to rivet rupture. As per the
SB 72-0365 issued dated 22.02.2023, the incident involved Engine#2 s.no 602691
equipped with Inner RDS s.no EE856110 is listed in the SB.

All the concerned Airworthiness Directive, Mandatory Service Bulletins, DGCA

Mandatory Modifications on this aircraft and its engines has been complied with
as on day of the event. There were no abnormal observations noticed by airline
engineering during the compliance of the ADs & SBs.

The defect record of the aircraft was scrutinized on the date of occurrence of the
incident and observed that LH Ignition system for ENG#1 declared inoperative,
MEL 74-00-01-01B under CAT’C’ invoked on 01.05.2022 and valid up to
11.05.2022. There were no other defects recorded.

Post incident, the engineering interrogated and found Flight Deck Effect-(FDE) -:
ENG #2 OIL FILTER BYPASS IND with Maintenance Message: 79-42895
CLIMB - OIL FILTER IMPENDING BYPASS ENG#2 ON. The failed ENG#2
did not have any previous ODMS maintenance alerts.

On examination of Engine#2 ODMS sensor found metallic debris on the magnetic

tip and further on scavenge screen inspection found metallic particles in
Accessory Gear Box (AGB) Sump, Transfer Gear Box sumps i.e., TGB1 &
TGB2. The involved ENG#2 S.no 602691 was sent to manufacturer facility for
investigation.

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 During detailed examination, it was identified that the RDS ball bearing has failed
and the most probable scenario of the RDS ball bearing failure was attributed to
the following observations –

1. The progressive rupture of the rivets and pockets of the cage and
blocking the balls in position.
2. There were inner ring axial marks and sliding all over the outer ring
raceway circumference and observed total cage rupture.
3. There was overheating & ball sliding on inner and outer rings.
4. And, secondary spalling on outer ring raceway and balls was observed.

M/s CFM has identified the root cause of all the RDS ball bearing failures, is due
to the insufficient oil film between cage pilot diameter & inner ring of the ball
bearing and the riveting gaps which contribute to abnormal stress.

M/s CFM has addressed the root cause of the RDS ball bearing failures through
the Service Bulletins SB 72-0258 (Cat 3) Issue no. 003 dated 04.11.2022, SB 72-
0271 Issue no. 02 dated 11.08.2020 and advised the operators to comply the SB at
next visit of engine or module.

From the above it is inferred that the ENG#2 Radial Drive Shaft ball bearing cage
rivet failure was cause for the IFSD incident.

3. CONCLUSIONS

3.1 Findings:

1. The Certificate of Airworthiness and the Certificate of Registration of the

aircraft was valid on the date of incident.
2. The certificate of flight release was valid on the day of incident.
3. All the concerned Airworthiness Directive, mandatory Service Bulletins,
mandatory modifications on this aircraft and its engine have been complied
with as and when due.
4. The aircraft was cleared by engineering at Chennai and from the defect record
of the aircraft it was observed that LH Ignition system for ENG#1 declared
inoperative, MEL 74-00-01-01B under CAT’C’ invoked on 01.05.2022 and
valid up to 11.05.2022.
5. The aircraft weight and CG were within limits.
6. Both crew members were appropriately qualified to operate the flight. The PIC
was PF (Pilot Flying) and FO was PM (Pilot Monitoring).
7. At 14:20:21UTC, aircraft at 9460feet, the Oil Filter Bypass ENG#2 light was
illuminated and remained. Crew carried out the checklist as per FCOM
procedure and shut down the engine and declared PAN PAN to ATC.

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 8. The aircraft made a safe single engine landing at Chennai and taxied on its own
power to the parking bay. There was no injury to any of the occupants onboard
the aircraft and there was no fire.
9. No external damage to the aircraft.
10. The recorded landing g-value was 1.072g, which is within the AMM limits and
it is not a hard landing.
11. Crew actions were satisfactory and in compliance of the FCOM
procedure/checklists.
12. Both the cockpit crew had undergone pre-flight medical examination prior to
flight and same was negative.
13. Weather was not a factor to the incident.
14. M/s CFM has identified two batches of RDS ball bearing cages, where all the
RDS bearing failure events occurred. The involved RDS bearing cage belongs
to one of the batches i.e., M13685.
15. M/s CFM has identified the root cause of all the RDS ball bearing failures, is
due to insufficient oil film between cage pilot diameter & inner ring of the ball
bearing and the riveting gaps which contribute to abnormal stress.
16. Post incident, the examination of Engine#2 found metallic debris on the
magnetic tip of ODMS sensor, AGB sump and TGB sumps i.e. TGB1 & TGB2.
17. The engine strip inspection was carried out at manufacture facility and the shop
report reveals that RDS ball bearing cage rivet was failed.
18. M/s CFM has addressed the root cause of the RDS ball bearing failures through
the Service Bulletin SB 72-0258 (Cat 3) Issue no. 003 dated 04.11.2022, SB
72-0271 Issue no. 02 dated 11.08.2020 and advised the operators to comply the
SB at next visit of engine or module.

3.2 Probable Cause:

The cause of the incident is due to the ENG#2 Radial Drive Shaft Ball Bearing
cage rivet fatigue failure.

4. Safety Recommendations:
1. The compliance of Service Bulletin may be monitored by DGCA.

(Preetham Reddy N)
Assistant Director of Air Safety
Investigator-in-Charge
Place: Chennai
Dated: 26.04.2023.
------END OF THE REPORT------
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